NGUYN T!

C S" D#NG KHNG SINH

ul Luong: uuoc 4, h chlnh quy
1hl luong: 4 uL
TS. !"ng Nguy#n !oan Trang
ThS. !on V$n Khnh
N| dung
A. 1|nh h|nh d khng khng s|nh
8. Nguyn tc s dqng hp |y kS trong d|u tr[
1) Ch| d[nh kS ph hp v| tc nhn gy bnh
2) Lqa chn kS d|u tr[ th|ch hp
!" #$ &'() *+, *-./ 0'1- 12-'34 567 &8)
9" #$ &'() *+, :!) 0-' 7; 0<* =)> ?' :'1-
3) ung s dqng kS hp |y
4) L|u |ung v khong cch dng ph| d v h|u qu
S) 1h| g|an d|u tr[ v| kS th|ch hp
6) h| hp v| cc phuong php d|u tr[ h tr
C. Nguyn tc s dqng hp |y kS trong dq phng phu thut
D. Ch|n |uc c| th|n nnh h|nh s dqng khng s|nh
Mqc nu hc tp
1) Clal Lhlch duoc ly do phal Lun Lh cc nguyn Lc s dung kS
2) 1rlnh bay duoc nguyn Lc xc mlnh su nhlm khun
3) 1rlnh bay duoc cc yu L anh huong dn vlc lua chon kS/
phl hop kS va dung s dung kS Lrong dlu Lrl Lheo klnh
nghlm luc du va dlu Lrl sau khl c kL qua vl slnh hoc
4) 1rlnh bay duoc nguyn ly duoc dng-duoc luc hoc ca kS
Lrong vlc lua chon llu va khoang cch dung ca kS
3) 1rlnh bay duoc cc yu L anh huong ln Lhl glan dlu Lrl kS
6) 1rlnh bay duoc nguyn Lc lua chon loal kS, dung s dung va
Lhl glan s dung kS du phng Lrong phu LhuL
A. 1|nh h|nh d khng khng s|nh
nm 1969: 8ob oblm ttoq J bl cb oqo - bc sl Wllllam
SLewarL, M
8o co Lhln Lal-dlch bnh Lh gll nm 2000 ca WPC: 8nh
nhlm Lrung la k glL ngul ln nhL (13 Lrlu ngul chL Lrong
nm 1999)
A. 1|nh h|nh d khng khng s|nh
Su Ll xuL hln (hl slnh) ca mL s bnh nhlm Lrung:
lao, sL reL, sL xuL huyL, La
Cc vn d m| ny s|nh trong bnh nh|m trng:
Nh|m trng ||n quan dn chm sc y t
c kl LhuL xm ln, suy glam mln dlch, qu Lal bnh nhn, Lhlu
nhn luc y L
V| khun da d khng thuc:
MS: MeLhlclllln-reslsLanL 5topbylococcos ooteos
vk. voocomyclo-teslstoot otetococcl
S8s: xLended-specLrum 8eLa-lacLamases
Mu-18: Mulu-drugs reslsLanL 1uberculosls
A. 1|nh h|nh d khng khng s|nh
a su khng || khng s|nh, k d khng c kha nng ch[u dqng 1
nng d kS cao hon so v| Vk b|nh thung ma khng bl uu
dlL
A. 1|nh h|nh d khng khng s|nh
Vk d khng @A !.+)2'1/:! BA 9!)4!11''
Meropenem 1 462
Im|penem 23 41
MkSA 1 | nhy cm ()
8 ho y 91
8 8ach Mal 100
1 | MkSA cn nhy cm v| vancomyc|n:
1 | d khng v| cc carbapenem:
S llu nm 200 ngun CAkl. 5l1uA1lON ANAl5l5-Aoublouc use ooJ keslstooce lo vletoom. 2010
A. 1|nh h|nh d khng khng s|nh
#A C1.)4/1'!. DA 7/5'
8 ho y nm 2003 61 316
8 8ach Mal nm 2003 201 13
8 8ach Mal nm 2006 2 213
8 8ach Mal nm 200 323 412
8 8ach Mal nm 200 336 422
1 | nt LS8Ls ca cc trqc khun gram (-) dung rut:
S llu nm 200 ngun CAkl. 5l1uA1lON ANAl5l5-Aoublouc use ooJ keslstooce lo vletoom. 2010
Co ch d khng
u khng Lu nhln:
uo h gen Lu nhln ca vl khun quy dlnh
u: .coll khng vancomycln do phn L vancomycln rL ln khng
Lhm duoc vao 18 vl khun
u khng Lhu nhn:
uL bln gen slnh ra gen d khng va Lruyn gen nay cho
cc Lh h vl khun up sau (d khng Lheo chlu doc)
1hu nhn gen d khng L cc vl khun khc qua cc
plasmld, Lransposon (d khng Lheo chlu ngang)
kybock. lbotmocotbetopy 2004, 24.20J5-2155
Vk d khng m|
t b|n

Vk nhy cm
Vk d khng
D| chuyn gen d khng
Co ch d khng
Cch thc d khng ca v| khun
1ao enym bL hoaL/ ph hy
khng slnh
8ln dl dlm Lc dng ca khng
slnh
Clam nh Lhm ca khng slnh vao
Lrong vl khun
1hay dl con dung chuyn ha
1ao ra bm nguoc (-gp)
levy 58. 5cleoufc Ametlcoo. 1998. 46-5J
u t gp phn gy d khng
u L Lhuc v vl khun:
kha nng nhn dl rL nhanh
c suL dL bln gen Lrong qu Lrlnh sao m
u L Lhuc v ngul s dung:
slnh bnh vln (qu Lal 8n, dlu kln S, sL Lrung)
S dung kS khng hop ly:
khng dung kS, dung kS khl khng cn LhlL
khng d nng d kS (llu, khoang cch, duoc dng hoc ca kS)
khng d Lhl glan
uung kS Lhung xuyn (bnh vln, cng dng, gla suc)
am dung khng slnh ph rng
Sq pht tr|n khng s|nh
Gerard D. Wright. Nature Reviews. Microbiology 5, 175-186 (2007)
Sq pht tr|n khng s|nh m|
0
2
4
6
8
10
12
14
16
1983-1987 1988-1992 1993-1997 1998-2002 2003-2008
h hoaL chL Lrong Lng s 223 Lhuc ml Lrong glal doan
199-2002 (3) la cc kS
12 kS ml duoc dua vao s dung L 199
8oocbet, et ol. clu 2009, 48.1-12
Sq pht tr|n khng s|nh m|
khng s|nh Nm ph duyt Nhm kS m|
lapenune 199 khng
ulnuprlsun/daloprlsun 1999 khng
Moxloxacln 1999 khng
Cauoxacln 1999 khng
L|neo||d 2 ao||d|none
edlLoren plvoxll 2001 khng
rLapenem 2001 khng
Cemloxacln 2003 khng
Daptomyc|n 23 L|popepnde
1ellLhromycln 2004 khng
1lgecycllne 2003 khng
uorlpenem 200 khng
Sq pht tr|n khng s|nh m|
1n hot cht Nhm
ung
dng
Ch| d[nh L|u
eoblprole ephalosporln
cSSS
hase : , P
hase : n1 mu
300mg 8u
earollne ephalosporln
cSSS,
u duyL nm 2010
600mg 12h
claprlm
ulamlno-
pyrlmldlne

cSSS
hase : P, P,
0- 16 mg/kg 8u
1elavancln Clycopepude
cSSS
hase : P
10mg/kg hang ngay
CrlLavancln Clycopepude
cSSS
hase : n1 mu L
caLheLer
400-00mg hang
ngay
1200mg x1
eLhromycln
2nd generauon
keLollde
C

hase : vlm xoang
300mg dally
amoplanln
Clycollpo-
depslpepude
C uu 200 hoc 400mg 8u
ot
nh
trn
MkSA

c555l. compllcoteJ sklo ooJ sklo sttoctote lofecuoo
CDAD: Clostridium difficile-Associated Diseases
1|n tr|nh d|u tr[ mt bnh nh|m trng
8uc 1
c m|nh yu cu d|u tr[ kS v c gng c d[nh tc
nhn gy bnh
8uc 2
8uc 3
8uc 4
8uc S
1|n tr|nh d|u tr[ mt bnh nh|m trng
8uc 1
c m|nh yu cu d|u tr[ kS v c gng c d[nh tc
nhn gy bnh
8uc 2 Lqa chn phc d kS d|u tr[ theo k|nh ngh|m |c du
8uc 3 1heo d| d|u tr[ kS ban du: h|u qu v dc nh
8uc 4
8uc S
1|n tr|nh d|u tr[ mt bnh nh|m trng
8uc 1
c m|nh yu cu d|u tr[ kS v c gng c d[nh tc
nhn gy bnh
8uc 2 Lqa chn phc d kS d|u tr[ theo k|nh ngh|m |c du
8uc 3 1heo d| d|u tr[ kS ban du: h|u qu v dc nh
8uc 4
|u ch|nh kS d|u tr[ theo tc nhn gy bnh
d duc c d[nh
8uc S 1heo d| d|u tr[: h|u qu v dc nh
8, Nguyn tc s dqng hp |y kS trong d|u tr[
1) Ch| d[nh kS ph hp v| tc nhn gy bnh
2) Lqa chn kS ph| hp kS d|u tr[ ph| th|ch hp
o) k5 Jlo ttl tbeo klob oqblm loc Jo
b) k5 Jlo ttl soo kbl c kt poo vl slob
3) ung s dqng kS ph| hp |y
4) L|u |ung v khong cch dng ph| d v h|u qu
S) 1h| g|an d|u tr[ v| kS ph| d h|u qu
6) h| hp v| cc phuong php d|u tr[ h tr
1. Ch| d[nh dng kS ph| ph hp v| tc nhn
gy bnh
Ch| dng kS kh| c nh|m khun:
Cn c m|nh sq nh|m khun ! chng m|nh yu cu v
|y do s dqng kS
uung kS du phng nhlm khun: cn phu hop
S dung sal/ khng hop ly/ lam dung kS:
am Lng nhanh su d khng ca k
1ng nguy c dc nh
1ng chl phl dlu Lrl
c m|nh sq nh|m khun
a, 1r|u chng v du h|u:
1oan Lhn: sL
L Lhung: sung, d, chay m
c du hlu khc c Lh hu lch
c ch du vlm nhlm: S (S), , procalclLonln
S luong bach cu (W8), 8 Lrung nh, band
8 hoc k hln dln Lrong mu, dlch no Ly,
nuc uu
c xeL nghlm khc: dung huyL, phn ch nuc uu
c m|nh sq nh|m khun
b, N nm v| khun gy bnh
Cy v| khun (v th d nhy cm v| kS)
Nh|m trng nng hoc nh|m trng v| khun d khng
nhum Cram, sol klnh hln vl
han ung huyL Lhanh hoc,
!uu y: mu lm sang (mu, 8, dam, dlch r vL Lhung,
nuc uu) cn |y truc kh| kh| du kS d|u tr[
1h ngh|m d nhy cm ca Vk v| kS
(th ngh|m kS d)
| tr[ MIC:
S: Nhy cm
I: Nhy cm va ph|
k: khng

M la nng d Lhp nhL ca kS ngn su Lng slnh ca k quan sL
duoc sau khl Lrong ml Lrung nul cy dc hlu Lrong 24 gl
| tr[ ny dc h|u cho c khng s|nh v v| khun
8, Nguyn tc s dqng hp |y kS trong d|u tr[
2. Lqa chn phc d kS d|u tr[ ph| th|ch hp:
Cho h|u qu t| uu nht:
ulu Lrl hoc ngn nga duoc nhlm Lrung vl Lhl glan
dung kS ngn nhL
lL Lc dung phu nhL
Clam Lhlu Ll da su xuL hln va lan Lruyn k d
khng
hl phl hop ly nhL
8, Nguyn tc s dqng hp |y kS trong d|u tr[
2. Lqa chn kS ph| hp kS d|u tr[ ph| th|ch hp:
a, ua chon kS/ phl hop kS dlu Lrl Lheo klnh
nghlm luc du
b, ua chon kS/ phl hop kS dlu Lrl sau khl c kL
qua cy vl khun va kSu
Th!i "i#m
ch$n "on/
nghi ng!
nhi%m
trng
Th!i "i#m
c k&t qu'
c(y VK v
KS)
kS theo k|nh ngh|m |c du kS sau kh| c kt qu v| s|nh hc
!nh nhanh !
!nh m"nh !
!nh lin t#c !
Cc yu t cn cn nhc em t kh| |qa chn kS d|u tr[
8nh nhn
nhng k gy bnh Lhung gp
Lal nl dlu Lrl
k c kha nng gy bnh cao
nhL o bnh nhn
Muc d d khng Lal nl dlu Lrl
u Lruc ha hoc, c ch Lc dng
uuoc dng/ uuoc luc ca kS
uc nh ca kS
Su d khng ca k vl kS
hl phl
l Lrl nhlm Lrung
Muc d nhlm Lrung
1ul
1lnh Lrang 8n (c Lhal, )
huc nng gan-Lhn, h mln dlch
8nh kem Lheo, kha nng Lun Lh
khng s|nh
V| khun
a. Lqa chn kSph| hp kS d|u tr[ theo k|nh
ngh|m |c du
|u qu |m sng | quan trng nht:
kS lua chon cn phu hop vl Lc nhn k nghl ng/d blL
va phu hop vl kL qua kS d/muc d d khng ca k Lal
nl dlu Lrl
Lqa chn kSph| hp kS dqa trn:
V[ tr| nh|m trng
uu don nhng k c kha nng gy bnh (hn Lham khao-Lu hoc)
n c Lh glup chon llu va dung s dung kS (u: nhlm Lrung nl
Lm mac, mang no, xung khp cn dung kS dung um, llu cao
va Lhl glan dal)
1|nh trng bnh v co d[a bnh nhn
Nhi%m trng ph*i-VPC)
Vim tai gi+a
Vim mng no
Nhi%m trng da-m m,m
Nhi%m trng * b-ng
Nhi%m trng ".!ng ti#u d./i/ vim bng quang
Nhi%m trng ".!ng ti#u trn/ vim th0n-b# th0n
Vim vng ch0u
1|nh trng, co d[a bnh nhn
1|n s d[ ng thuc:
ul ung penlclllln: cn nhc khl chon kS nhm beLa-
lacLam
1ype (shock phan v, co LhL ): chng ch dlnh cc
penlclllln, cephalosporln, carbapenem
non-Lype (ban d da): c Lh dung cephalosporln (dl ung
cheo 3-10)
1|nh trng co d[a bnh nhn
Suy g|m chc nng gan-thn:
1hn la c quan dao Lhal phn ln cc kS:
mlnoglycosld, vancomycln, beLa-lacLam
Can la c quan chuyn ha chlnh d dao Lhal mL s kS:
llndamycln, macrolld, meLronldaol, chloramphenlcol va rlampln
1lch Lu cc kS, Lng nguy c dc nh nu khng chnh llu:
uc Lhn: amlnoglycosld, vancomycln, collsun, sulamld, LeLracyclln Lh
h 1, mL s cephalosporln
uc gan: Lhuc khng lao, nlLrouranLoln, chloramphenlcol,
1hung phal chnh llu kS Lhal qua Lhn khl lcr < 30 m/phuL
1|nh trng co d[a bnh nhn
hq n c tha|:
nguy c dl LL Lhal nhl do kS:
enlclllln, cephalosporln va eryLhromycln: an ton
1lcarclllln, meLronldaol: qul Lhal o dng vL
1eLracyclln: vang rng, hu men rng, anh huong phL Lrln xung
ulnolon, rlampln, LrlmeLhoprlm: slnh qul Lhal chua blL r
1|nh trng co d[a bnh nhn
1u| tc:
k gy bnh Lhay dl Lheo Lul: u: vlm mang no do k:
1r s slnh: llstetlo spp. a 5tteptococcos spp. nhm 8
ngul Lruong Lhanh: 5. poeomooloe va Nelssetlo meoloqluJls
ngul gla: 5tteptococcos poeomooloe and llstetlo spp.
huc nng gan - Lhn Lhay dl Lheo Lul:
huc nng Lhn glam o Lr slnh non, Lr s slnh, ngul gla
ML s kS khng nn dung cho Lr nh: qulnolon, LeLracyclln
1|nh trng co d[a bnh nhn
Cc bnh |y bt thung km theo:
c bnh gy glam mln dlch: khl u, 8n ghep c quan, P:
u dua dn nhlm Lrung
1hung phal chon kS manh, loal dlL khun va dung Lhl glan dal hn
8L Lhung Lrn dl Lruyn hay chuyn ha:
8n bnh mach mu ngoal bln: glam hp Lhu kS dung M
8n Lhlu C6u: bl Ln mu khl dung sulonamld, nlLrouranLoln,
dapson, Lhuc Lrl sL reL va cloramphenlcol
1|nh trng co d[a bnh nhn
nh hung ca cc thuc dng dng th| truc d:
kS lua chon cn khc nhm kS d dlu Lrl Lruc d
Su hp Lhu ca kS qulnolon bl glam bol cc Lhuc chua
cauon da ha Lrl (anLacld, Lhuc b chua a, e)
h| hp kS d|u tr[ mt cch hp |y
h phl hop kS khl cn LhlL: muc dlch phl hop:
Plp dng Lc dung Lrn k d khng cao
hc d kS dlu Lrl Lheo klnh nghlm o 8n bnh nng khl
chua xc dlnh duoc k gy bnh va kL qua kS d
nl rng ph khng khun Lrong nhng nhlm Lrung gy ra
bol nhlu k
u: cepha 3 hoc uoroqulnlnolon + meLronldaol Lrong dlu Lrl
nhlm Lrung bung
ngn nga su xuL hln ca chng k khng Lhuc (dlu Lrl
lao, phong)
Mt s ph| hp kS cho tc dqng h|p dng
0c ch cc buc khc nhau/ qu Lrlnh chuyn ha:
SulameLhoxaol + LrlmeLhoprlm
Suladoxlm + pyrlmeLhamln
0c ch su bL hoaL kS gy bol enym:
hL uc ch beLa lacLamase + kS beLa-lacLam
lavulanaL + amoxlclllln
SulbacLam + amplclllln
1aobacLam + plperlclllln
1ng cung su Lhu nhn kS vao 18 k:
c beLa-lacLam + amlnoglycosld
mplclllln va genLamlcln
ealdlm va amlkacln
ancomycln + amlnoglycosld
8t || kh| ph| hp khng s|nh
| khng tc dqng:
enlclllln + clorLeLracyclln < penlclllln Lrong dlu Lrl vlm mang no do ph
cu (epper va uowllng, 1931)
mplclllln + cloramphenlcol + sLrepLomycln < amplclllln Lrong dlu Lrl vlm
mang no (MaLhles va cs, 196)
1rn chung penlclllln ph rng va amlnoglycosld ! bL hoaL
amlnoglycosld (Mcaughlln va cs, 191, l ! va cs, 192)
1ng ch| ph| d|u tr[
1ng tc dqng bt || (phan ung dl ung va dc nh ca kS)
b. Lqa chn kS kh| c kt qu v| khun v kS
ua chon Lheo kL qua vl khun gy bnh phn lp
duoc va kS d
hlnh xc nhL
lc cy k va lam kSu: cn Lhl glan va Ln chl phl,
Lhung ch p dung Lrong nhlm Lrung nng, lm sang
khng r rang hoc khng dp ung vl dlu Lrl
uu y: unh Lrang, c dla 8n, kha nng Lun Lh,
nh chL duoc dng-duoc luc ca kS, gl Lhanh
3. ung s dqng khng s|nh cn ph hp
1uy vao muc d nng ca nhlm Lrung:
nhlm Lrung nhe, dlu Lrl ngoal Lru: dung ung
nhlm Lrung nhe-Lrung blnh, dlu Lrl Lrong 8: dung um
M, hoc c Lh dung kS ung nhung phal c Sku cao
Slnh kha dung cao vl lneolld, uoroqulnolon, SMZ/1M,
meLronldaol (gn ! 100)
nhlm Lrung nng, de doa nh mang: dung um
4. L|u |ung kS v khong cch dng ph|
th|ch hp, d h|u qu
uyt tuong
No| tc
dng
Nng d khng s|nh
|u qu
d|u tr[
Ch d
||u
Duc dng hc ca kS
max
1max, 1
1/2
u
Duc |qc hc ca kS
M
0 6 18
24
12
N
%
n
g

&
'

MIC
AUC > MIC
AUC / MIC
T > MIC
Th(i gian C
KS
> MIC
C
max

Cmax / MIC
Th(i gian (h)
4. L|u |ung kS v khong cch dng ph|
th|ch hp, d h|u qu
Thng s) PK/ PD c*a KS:
33
c d|m khng khun ca kS
k|u d|t khun:
ulL khun phu Lhuc nng d:
ulL khun phu Lhuc Lhl glan (khng phu Lhuc
nng d)
PoaL nh khng khun ch Lng Lrong mL khoang nng
d nh (1xM Ll 4xM)
khoang Lhl glan ma nng d kS Lrn M Lung quan
vl hlu qua dlL khun
36
c d|m khng khun ca kS
|u ng hu kS ( = posL-anublouc eecL):
Plu luc uc ch k Lng Lruong vn xay ra khl
khng up Luc dung kS
1hung xay ra vl k gram dung, lL Lrn k gram
m
h c vl mL s nhm kS: amlnoglycosld,
uoroqulnolon, beLa-lacLam,
1hung lo vlvo > lo vltto
k|u tc dng ca kS
k|u 1 k|u 2 k|u 3
c d|m khng
khun
ulL khun phu
Lhuc nng d
dal
ulL khun phu
Lhuc Lhl glan
Ll Lhlu
ulL khun phu
Lhuc Lhl glan
dal
khng s|nh
mlnoglycosld
keLolld
luoroqulnolon
MeLronldaol
c -lacLam
ryLhromycln
llndamycln
lneolld
lLhromycln
1eLracyclln
SLrepLogramln
ancomycln
Mqc nu 1| uu ha nng d
1| uu ha th|
g|an np c v| kS
1| uu ha
|ung thuc
1hng s k D
quyt d[nh h|u qu
Cma , AC
1h| g|an C
kS
trn
MIC
AC
4. L|u |ung kS v khong cch dng ph|
th|ch hp, d h|u qu
Cma MIC -1
k|u 2 k|u 3 k|u 1
E 1|me MIC
> 0 u (Cr m)
> 40-30 u (Cr +)
AC
-24h
MIC
|uoroqu|no|on:
u
24h
/M > 123 (Cr m)
u
24h
/M > 40 (Cr +)
Vancomyc|n:
u
24h
/M > 123
(>400 vl k d khng)
khng s|nh am|nog|ycos|d
khong cch dng:
1heo Lruyn Lhng: Lng llu chla 3 ln/ ngay
1ng llu dung 1 ln/ ngay
nng d dnh cao hn
ult kboo tt boo, blo poo boo
lA Jl boo
nng d dy Lhp hn
lt Jc uob boo (qlom uob tbm coo k5 vo tbo/ tbl qloo?)
lA pbt boy tc Jooq kbl ooq J tbp boo oqooq ttl llo
khng s|nh am|nog|ycos|d
Dng 1 |n ngy so v| phc d truyn thng
khng s|nh am|nog|ycos|d
p dung ch d Lng llu dung 1 ln/ ngay:
uul 63 Lul
huc nng Lhn blnh Lhung
1hl glan dlu Lrl < 1 Lun
khng phal nhlm khun do otetococcl boc
lseoJomooos spp
S. 1h| g|an d|u tr[ v| kS ph| d h|u qu
khng c quy d[nh cq th
1uy Lhuc Lng 8n dua vao dp ung S va kL qua -quang, c Lh cn
hung dn ca chuyn gla nhlm Lrung
|u tr[ ngn ngy:
n1u1 khng phuc Lap/ n: 3 ngay
lm phl ngoal cng dng: 3 ngay
lm phl lln quan my Lho: ngay (Lr 8n nhlm lseoJomooos
hoc suy glam Mu)
|u tr[ d| ngy:
lm nl Lm mac, vlm Ly xung va apxe bung (4-6 Lun)
S. 1h| g|an d|u tr[ v| kS ph| d h|u qu
nguyn Lc chung: sau khl hL k dung Lhm kS:
2-3 ngay o 8n blnh Lhung
3- ngay o 8n suy glam mln dlch
1lu chl lm sang dnh gl hL k:
1h Lrang 8n cal Lhln (dau glam, glam ho, hL m )
S luong 8 va Lhn nhlL Lro v blnh Lhung
al Lhln Lrn -quang (c Lh mun hn cal Lhln S)
6. 1heo d| dp ng d|u tr[ v| kS
1hng s trn LS :
al Lhln Lrlu chung va du hlu (glam sL, um nhanh hoc ln ln),
al Lhln gl Lrl cn S (s luong 8 glam) va -quang (klch Lhuc vung
apxe glam)
kL qua vl slnh hoc:
1heo dl nng d kS/ mu:
mlnoglycosld
ancomycln
eL nghlm khc (chuc nng Lhn, gan)
kha nng dung nap vl kS ca 8n
6. 1heo d| dp ng d|u tr[ v| kS
l 8n khng cho dp ung vl dlu Lrl kS Lrong 2-3
ngay, cn dnh gl lal nhm xc dlnh:
hn don dung?
uaL duoc nng d Lrl llu kS/ mu?
8n c suy glam Mu?
8n c nhlm Lrung bl nhlm (apxe, vL la/ c Lh)?
hL Lrln k d khng?
. huong php d|u tr[ h tr
un luu phu LhuL hoc cL b m bl nhlm
ulu chnh dp ung vlm ca ky ch vl nhlm Lrung:
orucosLerold Loan Lhn: c lol Lrong dlu Lrl vlm mang no, vlm
phl do neumocysus o 8n uS
1am Lhl ngung hoc glam llu dlu Lrl vl cc Lhuc uc ch Mu
u L klch Lhlch dng 8 haL (8n glam 8 keo dal bl nhlm nm sol
xm ln)
Clobulln mln dlch, : Lrung ha dc L/ k Lrong dlu Lrl vlm mac
hoal Lhu do SLrepLococcl nhm
roblouc (cc chng loctoboclllos va 5occbotomyces): dlu Lrl
uu chay do c. Jl[clle
C. Nguyn tc s dqng kS dq phng trong phu
thut
khng s|nh dq phng: la kS s dung Lruc, Lrong va sau
mL qul Lrlnh chn don, dlu Lrl hoc phu LhuL d
ngn su nhlm Lrung
hu thut
c d|m
Sch
L m khng nhlm khun, khng vlm cp, khng Lhng vl dung h
hp, uu ha, mlng hu, dung slnh duc, dung uu, dung mL khng
c gln doan Lrong quy Lrlnh m v khun
Sch-nh|m
Mo Lhng c klm soL dung h hp, uu ha, mlng hu, dung slnh
duc, dung uu, dung mL vl luong r rL nh/sal sL kl LhuL nh
Nh|m
unh Lrang vlm cp, khng m hln dln o vL m luong r nhlu
L dung uu ha/Cln doan lu Lrong kl LhuL m
Do 1lnh Lrang nhlm khun hln r (apxe, m hoc m hoal Lhu hln dln)
1c nhn gy nh|m thung gp
hu thut V| khun thung gy nh|m
Lng ngqc-nm 5topbylococcos ooteos, sLaphylococcl coagulase (-)
1|u ha
1ruc khun gram m dung ruL, vl khun kl khl,
enLerococcl
hn phq (m do,
bqng, ct t cung qua
bqng)
1ruc khun gram m dung ruL, sLrepLococcl nhm
8, enLerococcl, vl khun kl khl
Ch|nh h|nh 5. ooteos, sLaphylococcl coagulase (-)
Mch mu
5. ooteos, sLaphylococcl coagulase (-), 1ruc khun
gram m dung ruL
C. Nguyn tc s dqng kS dq phng trong phu
thut
kS lua chon phal:
n Loan
1ung dl r un
PoaL nh dlL khun vl ph khng khun lo vltto
bao ph duoc loal vl khun c kha nng gy
nhlm Lrong khl phu LhuL
khng chon loc ra chng khng Lhuc
Cc cepha|ospor|n h khng khun
Cepha th h 1:
FGH12 )I12: eadroxll,
ephalexln,
FGH12 JK4L eaolln
Vk ram duong: 5ttep. pyoqeoes,
5ttep. vltlJoos, 5topb. ooteos, 5.
poeomooloe
Vk ram m: . coll, klebslello
poeomooloe, ltoteos mltobllls
Cepha th h 2:
FGH12 )I12L eaclor,
ceproll, euroxlme axeul
FGH12 JK4L eoLeLan,
eoxlun, euroxlme
Vk ram duong: Lung Lu cepha Lr
eoLeLan, eoxlun
Vk ram m: . coll, klebslello
poeomooloe, ltoteos mltobllls,
noemopbllos looeooe
Nelssetlo spp (Lr eoLeLan,
eoxlun)
Vk k[ kh|: eoLeLan, eoxlun
Cc cepha|ospor|n h khng khun
Cepha th h 3:
FGH12 )I12L edlnlr,
edlLoren, epodoxlme
proxeul, elbuLen, exlme
FGH12 JK4L
eoLaxlme,ealdlme,
eloxlme, erlaxone
Vk ram duong: 5ttep. pyoqeoes, 5ttep. vlrldans,
5topb. ooteos (mc ttooq bob), 5. poeomooloe
Vk ram m: . coll, klebslello poeomooloe,
ltoteos spp., noemopbllos looeooe
Nelssetlo spp , 8ottello botqJotfetl, val
otetoboctetloceoe
Cepha th h 4:
FGH12 JK4L eeplme,
ceplrom
Vk ram duong: 5ttep. pyoqeoes, 5ttep. vlrldans,
5topb. ooteos (mc ttooq bob), 5. poeomooloe
Vk ram m: . coll, klebslello poeomooloe,
ltoteos spp., noemopbllos looeooe
Nelssetlo spp , oblo otetoboctetloceoe,
lseoJomooos oetoqlooso
Cepha th h S:
FGH12 JK4L cearollne
Vk ram duong: nhlu loal k ca MS
Vk ram m: nhu cepha 3
Lqa chn kS dq phng
hu thut V| khun thung gy nh|m Cc kS khuyn co
Lng ngqc-nm
5topbylococcos ooteos, sLaphylococcl
coagulase (-)
Ceao||n, ceuro|me ,
vancomycln
1|u ha
1ruc khun gram m dung ruL, vl
khun kl khl, enLerococcl
Ceo|nn, ceotetan,
amp|c||||nsu|bactam,
ceao||n metron|dao|
hn phq (m do,
bqng, ct t cung qua
bqng)
1ruc khun gram m dung ruL,
sLrepLococcl nhm 8, enLerococcl, vl
khun kl khl
Ceo|nn, ceotetan,
ceao||n, amp|c||||n
su|bactam
Ch|nh h|nh 5. ooteos, sLaphylococcl coagulase (-)
Ceao||n, ceuro|me,
vancomycln
Mch mu
5. ooteos, sLaphylococcl coagulase (-),
1ruc khun gram m dung ruL
Ceao||n, vancomycln
*: Ch+ dng khi nghi ng( MRSA ho"c t, c-u coagulase (-), khng khuy.n co dng th/(ng quy
C. Nguyn tc s dqng kS dq phng trong phu
thut
ung s dqng:
0u un dung um vl cho nng d Ll uu Lal vl Lrl phu
LhuL Lrong suL qu Lrlnh phu LhuL
1h| d|m dng kS dq phng:
Lc rch da
kt thc 1
u tr u sm ng th| d|m
C. Nguyn tc s dqng kS dq phng trong phu
thut
1h| d|m dng kS dq phng:
1rong vng 1 gl Lruc khl rach da (Ll uu la Lruc rach da
30 phuL), Lrong vng 2 gl nu dung vancomycln
Lh phal cn nhng llu b sung Lrong khl phu LhuL
nhm duy Lrl nng d c hlu qua/ mu
1h| g|an dng kS dq phng:
khng qu 24 gl sau khl kL Lhuc phu LhuL (khng qu
4 gl vl phu LhuL um-lng nguc)
kS du phng sau khl dng vL m: cho Lhy khng c lol
D. Ch|n |uc c| th|n s dqng kS trong 8V
nng cao hlu qua dao Lao
y dung cc phc d va hung dn dlu Lrl
al Lhln cc xeL nghlm chn don
Cll han s dung kS
chln luoc quay vng khng slnh s dung
1| ||u tham kho
1 necuous ulsease SocleLy o merlca 8ad 8ugs and no urugs - 2004
2 SLeven berL ppllcauon o harmacoklneucs and harmacodynamlcs
Lo nublouc Selecuon &1 communlLy ol 29 no 4 (2004)
3 Surbhl eekha eL al Ceneral rlnclples o numlcroblal 1herapy Mayo
lln roc 2011,6(2):136-16
4 1reaLmenL Culdellne 1he Medlcal euer ol 3 (ssue 3) 200
3 C S Cuven and C uun rlnclples o good use o anubloucs ln hosplLals
!ournal o PosplLal necuon (2003) 33: 9196
6 lan Salklnd and kavlLha ao nublouc rophylaxls Lo revenL
Surglcal SlLe necuons merlcan amlly hyslclan, olume 3, number
3, March 1, 2011